Incorrect medical billing issues and misleading claims ranked in the top 10 complaints on the Consumer Federation of America report released on July 27th, 2017. The specific complaints related to patients receiving an incorrect bill for: 
- services they did not receive
- services that weren’t billed to their insurance company
- services that should have been covered by their insurance
- services that the patient had previously paid
One of the numerous examples the report gives is specific to a practice located in Georgia. According to the NACPI report on July 27th, 2017, “Numerous consumers contended that the practice billed them for services for which they’d already paid or failed to submit claims to their insurers in a timely manner, resulting in the claims being denied.” (p. 16)
These types of instances happen often when clinical and billing staff are not educated on how to determine when and if a patient owes a bill. Here are a couple of questions all of your staff should be able to answer in order to correctly bill your patients.
Why does the patient owe the practice?
Most of the time, there are only three reasons a patient should owe a bill. These reasons are the patients benefit specific copay, coinsurance, and/or deductible. Clinical and billing staff should be trained and tested on explaining patient responsibility.
Why did the insurance company deny the charges?
Unfortunately, a lot of times, untrained staff will send a denied charge straight to the patient. When an insurance denies a charge the denial should always be reviewed, corrected, and resubmitted. Insurance companies only allow a short time frame to correct or appeal medical claims. If you miss your chance to resubmit the claim, you are stuck writing off the charges that the provider rightfully earned. When this happens you have no appeal rights and may NOT bill the patient per the provider’s contract with the insurance company. Not only is this losing money for the provider, it is also incorrectly billing their patient.
Was the contracted adjustment taken off of the balance?
When a provider is contracted with a payer they agree to a set fee schedule (payment) for services.
For example, Dr. X’s payer contract states that he will be paid $65.00 for an injection procedure. Dr. X bills the insurance company a set $150.00 for the injection. When the insurance processes the claim they pay their agreed-upon $65.00 and tell Dr. X to adjust off the remaining balance of $85.00. Per Dr. X’s contract with the insurance company, he may NOT bill the patient for anything because the entire contracted amount was paid.
Can Your Staff Correctly Identify Contracted Adjustments?
Front desk staff, billing staff, and other support staff should be able to correctly identify and know what a contracted adjustment is.
These days, more often than not, insurance payments are posted electronically into the practice management system. This means the payment is automatically applied, adjusted, and transferred to the patient with the click of a button. For this reason, medical practices and billing departments must have good internal controls and processes in place to prevent inappropriate adjustments and inaccurately billing the patient.
For more information on how MEREM Healthcare Solutions can help you with your practice improve their revenue cycle and enhance practice performance, visit us at www.meremhealth.com or call 205.329.7519. Founded by healthcare executives as a solution to their on-going billing and coding problems, MEREM Healthcare Solutions has been providing exceptional medical billing and coding services to physician practices and ambulatory surgical centers since 2008. For nearly 10 years, we have been working to provide our clients with superior, off-site medical billing management services.